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“2 challenging patients successfully treated with serratus blocks using dexamethasone”
Thomas Hong, Stephanie Jones
Serratus anterior plane block (SAPB) is a common regional technique often utilized in the management of acute pain during the perioperative period. The procedure is beneficial for providing complete analgesia of the anterolateral hemithorax and can be an effective alternative to paravertebral blocks and thoracic epidurals.1 Although its use has become popular in acute pain, there has been limited literature on its use for chronic pain. We describe two cases in which, the SAPB with dexamethasone was utilized to successfully treat chronic anterolateral chest wall pain.
Case 1: Patient is a 53 yo F with PMH of multiple thoracic tarlov cysts who developed persistent bilateral circumferential chest wall pain with dysesthesia in the T6-7 distribution. Patient was initially responsive to conservative management with gabapentin but the pain reoccurred and became refractory to medication management. Patient initially trialed for right side serratus anterior plane block (SAPB) with 4ml of 0.25% bupivacaine and 10mg of dexamethasone under ultrasound guidance. Patient experienced greater than 50% pain relief on the right side and the left sided SAPB was performed 4 weeks later with similar results. Four months later, she remains pain free and has been able to carry out daily physical activities without major limitations.
Case 2: 69 yo F with no significant PMH w/ chronic right anterolateral chest wall pain, initially responsive to medication management with gabapentin but became refractory to medication management. Patient experienced temporary relief with right 7th and 8th intercostal blocks but unable to replicate the response with repeat injections. Patient subsequently trialed with right SAPB under ultrasound guidance with 4ml of 0.25% bupivacaine and 10mg of dexamethasone. Patient experienced significant pain relief with the SAPB. Three months later, she continues to have significant reduction in pain and has been able to carry out daily physical activities without major limitations.
SAPBs have become more prevalent since it was first described by Blanco et al in 2013 largely due to the safety profile, effectiveness, and technical simplicity of the procedure.3 The SAPB is typically performed under ultrasound guidance using the serratus muscle as its primary landmark. The serratus muscle is an easily identifiable, superficial anatomical marker that is traversed by the intercostal nerves after they emerge from the anterior rami of the spinal thoracic nerves to form a branching network of interconnected nerves that run within two potential spaces, one superficial and one deep to the serratus anterior muscle itself.1,2 The inclusion of steroid into the injectate enables SAPB to be an effective treatment option for chronic pain of the anterolateral chest wall while avoiding the potentially catastrophic side effects of paravertebral blocks and thoracic epidurals. SAPBs can also provide diagnostic utility in differentiating between musculoskeletal and visceral pain, helping avoid unnecessary investigations that may be costly or associated with complications.
1.Blanco R, Parras T, McDonnell JG, Prats- Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013, 68, 1107–1113
2.Durant E, et al, Ultrasound-guided serratus plane block for ED rib fracture pain control, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.07.021
3.Bossolasco M, Fenoglio L M. Ultrasound Guided Serratus Plane Block for Post-Mastectomy Pain Syndrome after Mastectomy with Axillary Node Dissection. J Anest & Intern Care Med. 2017; 3(1): 555604. DOI: 10.19080/JAICM.2017.03.555604.